Conclusion

Many empirical studies have shown that in Germany there are large differences in morbidity and mortality by education, occupation and income favouring the upper social classes. It is much more easy to describe than to explain these health inequali-ties, though, as the explanation has to incorporate a multitude of interrelated factors such as working and housing conditions, health behaviour and access to health care,

and as the effect can work in both ways: On one hand, low socio-economic status could lead to poor health (causation hypothesis), and on the other, poor health could lead to low socio-economic status (selection hypothesis).

The discussion on explanatory models is not very advanced in Germany, and there is no study that tried to assess whether the health inequalities found in Germany can mainly be explained by the causation hypothesis or by the selection hypothesis.

Drawing on studies from the United Kingdom showing that the causation hypothesis caries much more explanatory power than the selection hypotheses (Davey Smith et al. 1994), it can be assumed that the same is true for Germany as well, but we still don't know why poor health is "caused" by a low socio-economic status. Socio-eco-nomic status could influence health via a number of intermediate factors, it could be associated with many health relevant conditions, and to date only few of those have been analysed (e.g. physical and psychological stress at work).

The lack of vivid discussions on explanatory models in the German scientific com-munity corresponds with a lack of discussions on health inequalities in the general public, and also with a lack of programs addressed towards reducing health in-equalities, but slowly the situation seems to be changing now. For some years pov-erty is on the rise in Germany, it became a hot topic, and a number of conferences were specifically addressed towards the association between poverty and health.

Physician associations and State and Federal Ministries are also slowly starting to pay more attention to health inequalities. This "movement" is still rather weak, though, and the current health care reforms in Germany (that include a massive in-crease of the financial burden on the sick) indicate that health policy today is not de-signed to reduce health inequalities but rather to increase it.

Public commitment towards reducing health inequalities can also be assessed by re-viewing publications on interventions that are addressed to this problem. In a recent review, 67 publications have been found in international scientific journals (Gep-kens/Gunning-Schepers 1996), and none of the publications came from Germany.

This lack of contributions from Germany is partly due the small number of German researchers working on health inequalities, but it also indicates that in Germany few researchers and public health officials believe that health inequalities should and could be reduced. Most studies have been published from the USA, where differ-ences in health and health care by income and by race are much more pronounced than in Western Europe. Regarding Western European countries, most studies came from the United Kingdom and from The Netherlands. In these two countries health inequalities are probably not a much greater problem than in Germany, but experts working on health inequalities have been more successful than in Germany to make this a public issue.

It can be assumed that in Germany most health professionals and health policy makers are either not fully aware of the existing health inequalities, or that they be-lieve that they are doing already everything they can to reduce this problem. It is sometimes argued that in order to reduce health inequalities it is most important to reduce social inequalities in the first place, or that the association between poverty and health is primarily a problem of the social welfare system in general and not of

the health care system in specific. There is some truth in this argument, but it is easily misused as an excuse for passing the responsibility on to another authority. It would be most important to fight poverty, of course, but as long as poverty exists it is im-portant to reduce the association between poverty and health, and health pro-fessionals and health policy makers should accept their responsibility in this regard.

It can also be assumed that the lack of knowledge concerning health inequalities - and the believe that the existing health inequalities cannot be reduced - is shared by the majority of the population. These assumptions can be specified by the following hypotheses:

- It is widely known in all social classes that health inequalities exist favouring the upper social class, but the extent of these inequalities and the potentials to reduce them are largely underestimated.

- Health inequalities - as well as social inequalities - are widely accepted in all social classes as a fact of life that has to be taken as an expression of how our society is organised and how it rewards the upper class. This passive attitude could be over-come, for example, by asking member of the lower social classes about potential ways to improve their health status.

It is a strange situation that for many years empirical information has been accumu-lated showing that we are faced with a large public health problem, i.e. health in-equalities, that there is a lack of explanation and of programs designed to reduce this problem, and that still no study has been conducted that tried to fill these gaps by analysing the perception of health inequalities by the general public on one hand and by physician associations and health policy makers on the other. It would be interesting to know, for example, how members of the lower social class perceive the inability of researchers to explain health inequalities. We don't know the answer, but it can be assumed that there is a lot of mocking at these "experts" who don't even care to ask those who are most affected.